Use of Pulmonary-Artery Catheters in High-Risk Surgical Patients
In this large trial, elderly, high-risk patients were randomly assigned before surgery to goal-directed therapy guided by a pulmonary-artery catheter or to standard care without the use of such a catheter. There was no significant difference between the groups in mortality in the hospital or at 6 or 12 months. Pulmonary embolism was more frequent in the catheter group.
These findings argue against the routine use of a pulmonary-artery catheter in caring for elderly, high-risk patients during and after surgery.
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Natalizumab for Multiple Sclerosis
Natalizumab is an antagonist of  4 integrin, a very late adhesion antigen that is expressed on the surface of activated lymphocytes and monocytes. In this double-blind, placebo-controlled trial, the patients who received natalizumab had fewer new enhancing lesions on gadolinium-enhanced magnetic resonance imaging and significantly fewer relapses.
This carefully controlled trial involved patients with relapsing multiple sclerosis. The follow-up lasted six months, so longer studies are needed, but the results indicate that treatment with agents that inhibit adhesion and transendothelial migration of activated immune cells may offer clinical benefits.
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Natalizumab for Active Crohn's Disease
In this 12-week randomized, placebo-controlled study of patients with active Crohn's disease, natalizumab, an 4 integrin–specific humanized monoclonal antibody, did not result in a significantly higher rate of clinical remission at 6 weeks (the prespecified primary outcome measure). However, analyses of secondary outcome measures suggest that natalizumab reduced disease activity and improved the quality of life.
This study suggests that 4 integrin is important in Crohn's disease. The value of natalizumab relative to other available treatments for Crohn's disease is not yet known.
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Hallervorden–Spatz Syndrome
Hallervorden–Spatz syndrome is an autosomal recessive disorder characterized by dystonia, parkinsonism, and brain iron accumulation. The authors found that all patients with classic disease (characterized by early onset and rapid progression) and one third of patients with atypical disease (later onset and slow progression) had mutations in the gene encoding pantothenate kinase 2 (PANK2 ). All patients with PANK2 mutations had a characteristic abnormality on magnetic resonance imaging of the brain.
Many patients now classified clinically as having Hallervorden–Spatz syndrome can be better described as having neurodegeneration associated with PANK2 mutations.
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Clinical Practice: Preventing Falls in Elderly Persons
A 79-year-old woman with a history of congestive heart failure, arthritis, depression, and difficulty sleeping presents for a follow-up visit. She takes several prescription medications, including an antidepressant, a diuretic, an angiotensin-converting–enzyme inhibitor, and a beta-blocker, as well as over-the-counter sleep and allergy medications. Her chronic conditions appear to be stable. Her daughter reports that the patient has fallen twice during the past six months. What can be done to prevent future falls?
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Genomic Medicine: Population Screening
Newborns are now routinely screened for the presence of a number of inherited diseases. In these cases, early diagnosis allows treatment to be instituted before there are irreversible adverse consequences. However, as outlined in this installment in the Genomic Medicine series, clinical benefit can be derived from screening adults as well — not only for the genes associated with classic inherited conditions, such as cystic fibrosis and Tay–Sachs disease, but also for genes that are better considered risk factors for complex diseases, such as factor V Leiden and mutations associated with hereditary hemochromatosis.
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Clinical Problem-Solving: Easy to See but Hard to Find
A 46-year-old woman from the Philippines reports fatigue, body aches, and weight loss. On examination, she is pale and has diffuse bony tenderness. The hemoglobin level is 8.0 g per deciliter; the white-cell and platelet counts are normal. The serum creatinine level is 2.8 mg per deciliter (247.5 µmol per liter), and the serum calcium level is 13.2 mg per deciliter (3.3 mmol per liter).
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